Provider Demographics
NPI:1972526556
Name:GOAD, JAMIE D (DDS)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:D
Last Name:GOAD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 HARPER DR NE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3587
Mailing Address - Country:US
Mailing Address - Phone:505-823-8528
Mailing Address - Fax:505-823-8555
Practice Address - Street 1:710 AVENUE E
Practice Address - Street 2:
Practice Address - City:CARRIZOZO
Practice Address - State:NM
Practice Address - Zip Code:88301
Practice Address - Country:US
Practice Address - Phone:505-648-2839
Practice Address - Fax:505-648-4113
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1324122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84285Medicaid
NMPENDINGMedicare UPIN
NM84285Medicaid